WORLD HEALTH ORGANIZATION EB89/INF.DOC./14 ORGANISATION MONDIALE DE LA SANTE 2 1 J a n u a r y 1 9 9 2
EXECUTIVE BOARD
E i g h t y - n i n t h S e s s i o n A g e n d a i t e m 7 . 1
A PARADIGM FOR HEALTH
Introduction by the Director-General
M r Chairman, distinguished members of the Executive Board, ladies and gentlemen,
It is a year since I shared with you m y perception of how changing socioeconomic and political realities are affecting health development, and of the need for a paradigm for new public health action. O f course, not only influences external to health, but relatively new diseases, such as A I D S , established diseases such as tuberculosis and malaria，and diseases of the elderly, have severe implications for development. Astounding changes are taking place around us - at global, regional and national levels - and they wiU have major
implications for the way people live and function. "The old order changeth, yielding place to new" is certainly true, but generally people absorb and adapt to changing realities, while having little chance as individuals to influence them. I feel that W H O must help its M e m b e r States to anticipate these changes and to take steps to mitigate their untoward effects, especially on health. Unless w e take steps to ensure these linkages, mere prevention and solution of health problems need not affect socioeconomic development or the social policy, and will lead to further marginalization of the health sector and weaken the sustainability of our efforts. I presented some of m y ideas to the Executive Board in January 1991 and to the Programme Committee of the Executive Board in July. I have spoken about them at some sessions of the regional committees. In document EB89/11 I attempt to consolidate some of the implications of findings from the second evaluation of
implementation of the global strategy for health for all, and ideas that I would like you to reflect upon.
So far, the health-for-all strategy is being implemented as envisaged at the time it was formulated in 1979. It is clear that, in general, M e m b e r States have adopted the primary health care approach as described in the Declaration of Alma-Ata, and in accordance with W H O ' s guiding principles, for the development of their health systems. The evaluation report shows that, while there have been improvements in health, the gap between the least developed countries and other developing countries has widened, and disparities have
increased within countries and possibly a m o n g certain population segments. However, when the health-for-all concept is viewed in a broader context, it is clear that the health-for-all indicators used for the evaluation do not comprehensively cover the full scope of the strategy; health for all means not only health for all people but also health during each phase of an individual life cycle. Such a broader vision brings to the forefront three major issues related to health systems development; coverage, accessibility and quality. Let m e elaborate.
It has traditionally been assumed that coverage is simply a question of numbers - the greater the number of people trained appropriately in health, the more extensive the coverage. But we know from experience that this is not so. W h a t is just as important is the existence of proper facilities which allow health workers to be productive. Accessibility requires consideration of not only where facilities are located within the community but also whether they are acceptable to local values and culture and also whether they are sustainable. Quality of care goes beyond having available highly trained health personnel and highly sophisticated technology, to consideration of whether they do what they are meant to do effectively and efficiently. These three
fundamental factors are unfortunately not given proper and balanced attention.
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We have to admit that, over the years, WHO has given insufficient attention to the diseases affecting the entire spectrum of the working population - from working children, to adolescents, adults and the working elderly. It is socioeconomically and perhaps politically essential that, in developed and developing countries alike, noncommunicable diseases, such as cancer and cardiovascular diseases, accidents, suicide, alcoholism and drug dependence, and psychosocial conditions such as dementia, now be given greater attention.
The evaluation has shown clearly that there is commitment to primary health care at the highest political level. This does not mean that health is in the hands of the politicians - but we must recognize that the politicians' perception of health is different from that of the health professional. There is also some success in social mobilization at community level. The weakness is the translation of political commitment into an equitable provision of health services in the community. This weakness is accentuated by global policies on economic adjustment; we need to see how public health action can mitigate it.
Too much focus is still being given to providing the best possible care for the individual, at the expense of public health measures that would benefit the whole community. But the ethics of what constitutes a proper balance among these, needs to be studied. The training of the health workforce has to be changed to reflect these issues. However, we should also remind ourselves that the way health workers, nurses for example, are paid, will influence their professional motivation and affect their aspirations.
The changes impinging on health which are occurring in our society will require the development of new indicators, since the existing indicators are not able to reflect or capture them. Economic issues will be central to decisions in the health sector. Health financing, and government budget systems in particular, are slow to follow changes taking place in macroeconomic policies. Many developing countries still adhere to an approach that gives responsibility for the provision of health care solely to governments through government health institutions; partnership with the private sector, nongovernmental organizations for example, has been minimal. Similarly, even where there have been shifts to market-based economies, medical care continues to be provided free. For example, I have been told that, in the Russian Federation, the health budget remains almost the same as it was during the earlier Union days which, of course, does not meet changing economic reality and the provision of medical care. With liberalization, however, the cost of pharmaceuticals and food for hospital patients has risen, following increases in market prices. With what is left in the budget, how can health care be supported? One can imagine the havoc this will cause, particularly for hospital care, which has been the main way of providing curative care in eastern and central European countries.
Health insurance is confined to only the working population. What about the unemployed? In some countries the uninsured may be as high as 30 per cent of the population. How will these people pay for their health care or for their insurance premiums, and if they cannot, who will pay, and how much? The same situation pertains for retired people, particularly women.
I have noticed at the various meetings I have attended that there is despondency and uncertainty on the part of health professionals about our ability to achieve health goals. I feel that such uncertainty is not because there is felt to be a lack of technical ability or ability to find financial resources, but rather it is a result of the rapidity with which changes are taking place, exceeding our ability to adapt.
To summarize, the goal of health for all and the primary health care approach remain as valid today as they were in 1978. The global strategy for health for all by the year 2000 was, however, a paradigm for advocacy. The Eighth General Programme of Work was a good planning tool. What we need now is a paradigm for public health action, to accelerate the achievement of health for all Member States and thus health for all people in the world over all phases of their life cycles, which will be the essence of the Ninth General Programme of Work.
There is a need to formulate a new paradigm for health as a result of changes that are occurring as we move from the 1980s into the 1990s and beyond. Interestingly enough, this paradigm shift is not confined to the health sector but is taking place throughout society, since it is driven by the political implications of a changing economic situation and changing international relationships. You may call it transition, mutation, a crisis of change, reform, restructuring or whatever you will.
Looking back at our old paradigm for primary health care, I sense that our programmes tended to be compartmentalized horizontally and/or vertically, constrained by limited resources and increasingly donor
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strategies which reflected current or changing conditions, management styles, or performance capabilities. W e advocated without providing support for action.
Our concern was to extend coverage; accessibility and acceptability to the users was not adequately assessed. There was much concern about details of the health care facilities, but less about their sustained support to ensure services of an acceptable quality. W e did not stress sufficiently the special needs of vulnerable groups in our societies. In addition, the international development arena was characterized by in-fighting and struggles for territory. Y o u may have noticed how many of the organizations of the United Nations system are themselves embarking on health activities, with a complete lack of coordination, which is particularly obvious at country level.
The new paradigm must therefore be formulated in a more genuinely democratic way, using change as the opportunity not reacting to crisis. The objective is to determine and rank priorities to meet basic human needs for development, and to select and implement those that are compatible with resources generated and available and have the possibility of success. This can be done only by means of a thorough situation analysis and prospective forecast, using currently available data, information and technology, giving due consideration to human rights based on social justice and equity. If W H O , with its M e m b e r States, is able to build a new health paradigm, then its leadership in health and development will be secure.
I know that to embark on such a challenging exercise to respond to current realities will be painful, but I a m convinced that, with your support, w e shall achieve our ends and W H O will keep its position as leader in this rapidly changing world.
